Driver Addition Form

This form will allow you to send us the required information to add a new driver to a passenger vehicle on your policy.

Make sure to have your current insurance certificate or policy on hand.

For your added protection, any change you make to your policy does not become effective until we contact you to verify the change and effective date. This is to protect your existing coverage, should additional information or coverage be required to make the change you have asked.

About you

Name(s) of insured(s)
(as named on your policy)   

1^st Named Insured:

2^nd Named Insured:

Your preferred means of communication for contact and follow-up :
 

E-mail

Phone

We can only accept changes from policyholders.
Please check this authorization box, before completing the rest of the form :
 

 I'm the owner of the policy and I'm authorized to submit these changes.

Disclaimer

E-mail address :

Daytime telephone number :

Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905      ext. : 

Home telephone number :

Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905   

Driver's First Name :

The initial of the middle name :

Last Name :

Date of birth :

  (dd / mm / yyyy)

Gender :

Male Female

Marital status :

Select Common law       Married Single Divorced Separated Other

Relationship to the insured :

Select Spouse Child Sister or brother Mother or Father Insured Other

Driver licence number :

What class of licence does this driver hold ?

Number of years with a valid driver's licence :

Select Less than 1 1-2 2-3 3-4 4-5 5-6 More than 6

Province or country where driver's licence issued :

Select Alberta British-Columbia Prince-Edward Island Manitoba New Brunswick Nova Scotia Ontario Quebec Saskatchewan Newfoundland North West Territories Yukon United States Europe Other country Without driving licence

Has this driver ever had their driver's licence suspended or cancelled in the last 3 years ?

Yes No

Has this driver taken and passed an official and recognized driver training course ?

Yes No

Has the driver been involved in a motor vehicle accident or presented any other type of auto insurance claim to an insurance company in the last 6 years ?

Yes No

If yes, please provide the details below :

1. Year:  

Month January February March April May June July August September October November December

Amount Less than $1 000 $1 001 to $5 000 $5 001 to $10 000 $10 001 or more

Nature of claim At-fault accident Not-at-fault accident At-fault accident for 50% Hit and run Fire - theft - vandalism Glass breakage Windstorm or hail

2. Year:  

Month January February March April May June July August September October November December

Amount Less than $1 000 $1 001 to $5 000 $5 001 to $10 000 $10 001 or more

Nature of claim At-fault accident Not-at-fault accident At-fault accident for 50% Hit and run Fire - theft - vandalism Glass breakage Windstorm or hail

3. Year:  

Month January February March April May June July August September October November December

Amount Less than $1 000 $1 001 to $5 000 $5 001 to $10 000 $10 001 or more

Nature of claim At-fault accident Not-at-fault accident At-fault accident for 50% Hit and run Fire - theft - vandalism Glass breakage Windstorm or hail

Has the driver had any traffic violations in the last 3 years ?
(Do not include parking violations.)

Yes No

If yes, specify :

How many MINOR traffic violations has this driver had in the last 3 years ?

  Select None 1 2 3 4 5 or more

How many MAJOR traffic violations has this driver had in the last 3 years ?

  Select None 1 2 3 4 5 or more

This new driver operates the following vehicle(s) :

Vehicle

Make

Year

Model

Type of driver

1

Select Principal Occasional

2

Select Principal Occasional

3

Select Principal Occasional

When will this change be effective ?   

(dd / mm / yyyy)

Company

If other, specify

Insurance policy number

Select Intact Insurance ING Novex ING Western Union Other